Laserfiche WebLink
SITE HEALTH AND SAFETY PLAN <br /> PART I PART II <br /> GENERAL SITE INFORMA ON EVALUATION OF POTENTIAL HAZARDS <br /> 1, Site Name; I. Chemicals Hazards <br /> Address: <br /> ❑Carcinogens: <br /> Contact Person: o: �Carrosives: <br /> Sweeps Number: <br /> ❑Dusts: <br /> Proposed Date of investigation/inspection: <br /> ❑Explosives: <br /> _E]Tlammables: <br /> 2. Description and brief narrative of inspection activity: -inorganic GasesaLe .. <br /> ❑New UST installation, ❑UAR Investigation. <br /> E]Tank Closure in Place. El metals: [� <br /> ❑Tank/Pipe Repair. <br /> ❑Tank/PI a Removal. - ❑Oxidizers: <br /> Tank/Pipe ❑Re-excavation. <br /> ❑PCB's: <br /> ❑Installation of Borings/Monitoring Wells. <br /> 3. Specific Site Information: PART III <br /> Tank No.: Tank Capacity: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank Content: Tank Age: I. Monitoring Equipment(note:Monitoring instruments must be used for all <br /> Other: operations unless appropriate rationale or restrictions are provided) <br /> { <br /> F1 Combustible Gas/Oxygen Meter. <br /> L+L <br /> 4. Type of Operation: ❑Detector Tubes(Specify). <br /> ❑Photo ionization Detector. <br /> 5. Release History: ❑Organic Vapor Analyzer. <br /> Evidence of leaks/soil contamination: ❑YES ❑NO ❑Other,specify. <br /> Documented Groundwater contamination: <br /> ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> & Potential Health and Satetv Level of Protection: ❑A ❑B ❑C <br /> Physical Concerns:(check all that apply&describe) PI-land Hat. <br /> Hear or Cold Stress: °F(high ambient temp.) <br /> afcty Glasses/goggles. <br /> Noise Sources: <br /> Leel toed/shank shoes or boots. <br /> xygen Deficiency: <br /> ❑Flame retardant coveralls. <br /> ❑Excavation:(falls,trips,slipping,cave-ins): Hearing protection. <br /> Tyvek. <br /> ❑Handling and Transfer of a Hazardous Substance:(fire,explosions, <br /> etc..): ❑Respirator: ❑APR ❑SCBA <br /> ❑Confined space entrv:(explosions): A/P cartridge: <br /> ❑Heavy equipment(physical injury&trauma resulting from moving ❑Safety vest. <br /> equipment): ❑Two-way communication. <br /> ❑Other,specify <br /> PART IV- PLAN APPROVAL <br /> 7. Anticipated Biological Hazards: <br /> Wnakes bnsects 00odents ❑Poisonous Plants <br /> Plan Prepared 6y: Date: <br /> ❑Other/Unknown(specily): <br /> ��/f <br /> 8. Narrative(provide all inRormation which could impact Health and Safety, Flan Approved by: Date: <br /> e.g.,power lines,integrity cif(likes,terrain,etc.) <br /> EH 23081 (1211712002) <br />